Provider Demographics
NPI:1659455483
Name:TABACK, BRET (MD)
Entity Type:Individual
Prefix:
First Name:BRET
Middle Name:
Last Name:TABACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27036
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10087-7036
Mailing Address - Country:US
Mailing Address - Phone:212-305-9576
Mailing Address - Fax:212-305-9480
Practice Address - Street 1:161 FORT WASHINGTON AVE FL 10
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3729
Practice Address - Country:US
Practice Address - Phone:212-305-9676
Practice Address - Fax:212-305-1522
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY237470208600000X, 2086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2701182Medicaid
NYA400035114Medicare PIN
NY2701182Medicaid